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;e�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'i' FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
�v-_ �' SlateForm43709 (R6/5-0G) '
� Prescnbed by Depariment of �ocal Govemment Finance
INSTRUCTIONS: � ile� �
To 6e filed in person or 6y mail with the County Audito� of the county whe�e the property is located.
Fi/ing Dates: 1) Rea/ Property: Dunng the 12 months before June Il of the year the deduciion is to be effe
2) Mobile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be eflective.
See reverse
num / legal description Record number �
a�—/ 7',J o2 ��� ��/ �W oC�/'number �(J� 7'
Asse ed value oi real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1,.FUrrent year owneR ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone olher than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hane pC 61.1-�
me of mortgagee or contract seller �
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and streer -" /� � � � �• �
(� 1.....
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Does applicant own property in any o��-, .. •••• jj � � Has this dedudion been requested on
county in Indiana? C�r ���, .. •••"' �„,�-Q �y property for current year? � Yes ❑ No
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�OUNTY AUDITOR
Dedudion approved in fhe amount of:
20 _Q� 20 Q� 20 20 20 20 20
P
Signature County Auditor Date
/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owhe/s full nam ) Person authorized by duty executed Power of Aftomey
/� or by IC 6-1.1-12-.07
Ful resident ddress of applicant Address of aulhorized person
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